Provider Demographics
NPI:1639233109
Name:HAYES, KIRK JACQUINE (ATC MPT CERT MDT)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:JACQUINE
Last Name:HAYES
Suffix:
Gender:M
Credentials:ATC MPT CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 OAK ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7012
Mailing Address - Country:US
Mailing Address - Phone:701-780-6000
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:1000 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-6000
Practice Address - Fax:701-780-5345
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6391225100000X
ND1139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist